Guideline scope Pelvic floor dysfunction: prevention and

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NICE guideline: Pelvic floor dysfunction in women: prevention and non-surgical management – final 1 of 24

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE

Guideline scope

Pelvic floor dysfunction: prevention and non-surgical management

The Department of Health and Social Care in England has asked NICE to

develop a new guideline on the prevention and non-surgical management of

pelvic floor dysfunction in women (including young women over the age of

12).

The guideline will be developed using the methods and processes outlined in

developing NICE guidelines: the manual.

This guideline will also be used to develop the NICE quality standard for pelvic

floor dysfunction.

1 Why the guideline is needed

A 2018 report by the Welsh Government concluded that a new ‘pelvic health

and wellbeing’ pathway was needed. This pathway would put more focus on

community-based preventive interventions and avoid using high-risk surgery

when possible, and would use specialist input to identify the small number of

women who do need surgery. NHS England also recognises that there should

be more focus on pelvic floor care, and on community-based preventive

measures and non-surgical management, and this will be one of the aims of

the NICE guideline.

On management, NHS England is currently reviewing the service specification

and commissioning of specialised services for women with complex pelvic

health issues, as part of the complex women’s surgery specifications. The aim

of the NHS England review is to ensure that women who need specialist care

https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview

https://gov.wales/vaginal-synthetic-mesh-tape-stress-urinary-incontinence-and-pelvic-organ-prolapse-review

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are correctly identified and referred to these centres. The centres themselves

will provide care and be able to meet professional standards for managing

complex pelvic organ prolapse and stress urinary incontinence.

Women may also benefit from more focus on community-based pathways that

include pelvic floor care and prevention of pelvic floor dysfunction. These

pathways are intended to reduce the number of women who develop complex

symptoms that would need specialist care (for example surgery), which is

another aim of this guideline.

Pelvic floor dysfunction

The pelvic floor is a funnel-shaped structure consisting of connective soft

tissue, including muscles tendons and nerves. It is responsible for

physiological functions related to the digestive system and the urogenital

organs.

'Pelvic floor dysfunction' covers a variety of symptoms. Definitions of pelvic

floor dysfunction vary, and an International Urogynecology Association and

International Continence Society consensus report has 250 separate

definitions of associated conditions, signs and symptoms. The following

symptoms will be addressed in this guideline as long as they are associated

with pelvic floor dysfunction: urinary incontinence, emptying disorders of the

bladder, faecal incontinence, emptying disorders of the bowel, pelvic organ

prolapse, sexual dysfunction and chronic pelvic pain syndromes. The 3 most

common and definable conditions are urinary incontinence, faecal

incontinence and pelvic organ prolapse.

Current practice

Individual women and patient groups have highlighted that the services

currently available are not meeting their needs, and may even be detrimental

to their health and wellbeing. This is a particular concern for surgical services.

There is currently no process in place to systematically identify which women

are at higher risk of pelvic floor dysfunction. For women who are at higher risk,

there are no lifelong or maternity-specific preventive strategies in place. The

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way that risks and reversible causes are identified and communicated at a

general and individual level also varies widely.

When pelvic floor dysfunction is diagnosed, there is variation in the availability

of and access to non-surgical management options, such as pelvic floor

muscle training. Women have no clear and effective strategies available to

prevent worsening of the condition.

Policy, legislation, regulation and commissioning

Since 2018 there has been a UK-wide 'pause' on the use of surgical mesh to

treat stress urinary incontinence and vaginally inserted mesh to treat pelvic

organ prolapse. The 'pause' reflects the importance of the arrangements set

out in the NICE interventional procedures guidance on mesh.

This guideline aims to optimise preventative and non-surgical strategies to

minimise the need for invasive treatment options. The NHS Long Term Plan

also addresses this by improving access to postnatal physiotherapy, to

support women who need it to recover from birth (see point 3.17 in the plan).

This will help to prevent urinary incontinence, faecal incontinence and pelvic

organ prolapse.

2 Who the guideline is for

This guideline is for:

• healthcare professionals in:

− primary/non-specialist care

− gynaecology services

− urology services

− continence services

− physiotherapy services

− colorectal services

− maternity services

• service commissioners

• health education providers

https://www.longtermplan.nhs.uk/

https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/a-strong-start-in-life-for-children-and-young-people/maternity-and-neonatal-services/

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• women using services, their families and carers and the public.

It may also be relevant for:

• staff in care homes

• private healthcare providers.

NICE guidelines cover health and care in England. Decisions on how they

apply in other UK countries are made by ministers in the Welsh Government,

Scottish Government, and Northern Ireland Executive.

Equality considerations

NICE has carried out an equality impact assessment during scoping. The

assessment:

• lists equality issues identified, and how they have been addressed

• explains why any groups are excluded from the scope.

The guideline will look at inequalities relating to age, ethnicity, pregnancy and

maternity, physical disabilities, cognitive impairment and gender

reassignment.

3 What the guideline will cover

3.1 Who is the focus?

Groups that will be covered

• Women, including young women aged 12 and older.

For simplicity of language this guideline will use the term 'women' throughout,

but this should be taken to also include people who do not identify as women

but who have female pelvic organs.

Specific consideration will be given to:

• women with suspected or confirmed pelvic floor dysfunction

http://wales.gov.uk/

http://www.scotland.gov.uk/

http://www.northernireland.gov.uk/

https://www.nice.org.uk/guidance/indevelopment/gid-ng10123

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• women who are pregnant or women after pregnancy (including women with

obstetric injury)

• women before and after gynaecological surgery (including women who

have had surgery for urinary incontinence or pelvic organ prolapse)

• women who are in perimenopause or postmenopause

• women aged 65 or older

• women with physical disabilities

• women with cognitive impairment.

Groups that will not be covered

• Men (see the equality impact assessment)

• Babies and children.

3.2 Settings

Settings that will be covered

• All settings where NHS-funded or local-authority-funded healthcare is

provided.

• Social care settings.

• Educational settings, if applicable.

3.3 Activities, services or aspects of care

Key areas that will be covered

We will look for evidence in the areas below when developing the guideline,

but it may not be possible to make recommendations in all the areas.

Public information strategies

1 Community-based pelvic health pathways

Preventing pelvic floor dysfunction

2 Identifying women at high risk of pelvic floor dysfunction

3 Lifestyle modifications

4 Physiotherapy (pelvic floor muscle training).

https://www.nice.org.uk/guidance/indevelopment/gid-ng10123/documents

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Non-surgical management of symptoms associated with pelvic floor

dysfunction (urinary incontinence, emptying disorders of the bladder,

faecal incontinence, emptying disorders of the bowel, pelvic organ

prolapse, sexual dysfunction and chronic pelvic pain syndromes)

5 Assessment for pelvic floor dysfunction

6 Information


8 Physiotherapy (pelvic floor muscle training)

9 Physical devices (including pessaries)

10 Psychological therapy

11 Behavioural approaches

12 Pharmacological management

13 Multidisciplinary pathways for non-surgical management of

pelvic floor dysfunction.

Note that the guideline recommendations for medicines will normally fall within

licensed indications; exceptionally, and only if clearly supported by evidence,

use outside a licensed indication may be recommended. The guideline will

assume that prescribers will use a medicine's summary of product

characteristic to inform decisions made with individual patients.

Areas that will not be covered:

1 Surgical management of pelvic floor dysfunction

2 Management of mental health conditions that are caused or exacerbated

by pelvic floor dysfunction.

Related NICE guidance

NICE has published the following guidance that is closely related to this

guideline. The most relevant recommendations have been listed in section 6.

Published

• Urinary incontinence and pelvic organ prolapse in women: management

(2019) NICE guideline NG123

• Antenatal care for uncomplicated pregnancies (2019) NICE guideline CG62

https://www.nice.org.uk/guidance/ng123

https://www.nice.org.uk/Guidance/cg62

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• Caesarean section (2019) NICE guideline CG132

• Stop smoking interventions and services (2018) NICE guideline NG92

• Intrapartum care for healthy women and babies (2017) NICE guideline

CG190

• Older people with social care needs and multiple long-term conditions


• Suspected cancer: recognition and referral (2015) NICE guideline NG12

• Postnatal care up to 8 weeks after birth (2015) NICE guideline CG37

• Falls in older people: assessing risk and prevention (2013) NICE guideline

CG161

• Mirabegron for treating symptoms of overactive bladder (2013) NICE

technology appraisal guidance 290

• Urinary incontinence in neurological disease: assessment and

management (2012) NICE guideline CG148

• Percutaneous posterior tibial nerve stimulation for overactive bladder

syndrome (2010) NICE interventional procedures guidance 362

• Generalised anxiety disorder and panic disorder in adults: management

(2011) NICE guideline CG113

• Weight management before, during and after pregnancy (2010) NICE

guideline PH27

• Faecal incontinence in adults: management (2007) NICE guideline CG49

In development

• Postnatal care up to 8 weeks after birth (update). NICE guideline.

Publication expected September 2020.

• Caesarean section (update). NICE guideline. Publication expected March

2020.

• Antenatal care for uncomplicated pregnancies (update). NICE guideline.

Publication expected December 2020.

NICE guidance about the experience of people using NHS services

NICE has produced the following guidance on the experience of people using

the NHS. This guideline will not include additional recommendations on these

https://www.nice.org.uk/guidance/cg132




https://www.nice.org.uk/guidance/NG12

https://www.nice.org.uk/guidance/CG37


https://www.nice.org.uk/guidance/ta290



https://www.nice.org.uk/guidance/ipg362

https://www.nice.org.uk/guidance/ipg362


https://www.nice.org.uk/guidance/ph27





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topics unless there are specific issues related to the prevention and non-

surgical management of pelvic floor dysfunction:

• Medicines optimisation (2015) NICE guideline NG5

• Patient experience in adult NHS services (2012) NICE guideline CG138

• Service user experience in adult mental health (2011) NICE guideline

CG136

• Medicines adherence (2009) NICE guideline CG76

3.4 Economic aspects

We will take economic aspects into account when making recommendations.

We will develop an economic plan that states for each review question (or key

area in the scope) whether economic considerations are relevant, and if so

whether this is an area that should be prioritised for economic modelling and

analysis. We will review the economic evidence and carry out economic

analyses, using an NHS and personal social services (PSS) perspective, as

appropriate.

3.5 Key issues and draft questions

While writing this scope, we have identified the following key issues, and draft

questions related to them:

Public information strategies

1 Community-based pelvic health pathways

1.1 What information strategies are effective in raising awareness about

prevention of pelvic floor dysfunction?

Preventing pelvic floor dysfunction

2 Identifying women at high risk of pelvic floor dysfunction

2.1 What are the non-obstetric risk factors (for example age, ethnicity

and family history, diet [including caffeine and alcohol], weight, smoking,

physical activity) for pelvic floor dysfunction?

2.2 What co-existing long-term conditions (for example chronic

respiratory disorders) are associated with a higher risk of pelvic floor

dysfunction?

http://www.nice.org.uk/guidance/ng5

http://www.nice.org.uk/guidance/CG138

http://www.nice.org.uk/guidance/CG136

http://www.nice.org.uk/guidance/cg76

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2.3 What are the obstetric risk factors for pelvic floor dysfunction?

2.4 What is the accuracy of prediction tools for identifying women at high

risk of pelvic floor dysfunction?


3.1 What is the effectiveness of modifying lifestyle factors (diet [including

caffeine and alcohol], weight loss, stopping smoking, physical activity)

for preventing pelvic floor dysfunction?


4.1 What is the effectiveness of pelvic floor muscle training for

preventing pelvic floor dysfunction?

Non-surgical management of symptoms associated with pelvic floor

dysfunction (urinary incontinence, emptying disorders of the bladder,

faecal incontinence, emptying disorders of the bowel, pelvic organ

prolapse, sexual dysfunction and chronic pelvic pain syndromes)

5 Assessment for pelvic floor dysfunction

5.1 What assessments should be conducted in non-specialist care to

identify whether the signs and symptoms at presentation are associated

with pelvic floor dysfunction?

6 Information

6.1 What information is valued by women with symptoms associated

with pelvic floor dysfunction and their partners or carers?

6.2 What information provision strategies are effective for women with

symptoms associated with pelvic floor dysfunction?


7.1 What is the effectiveness of weight loss interventions for improving

symptoms of pelvic floor dysfunction?

7.2 What dietary factors can increase or decrease symptoms of pelvic

floor dysfunction?

7.3 What types of physical activity can increase or decrease symptoms

of pelvic floor dysfunction?


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8.1 What is the effectiveness of pelvic floor muscle training (including

Kegel exercises, biofeedback, weighted vaginal cones, and electrical

stimulation) for improving symptoms of pelvic floor dysfunction?

9 Physical devices (including pessaries)

9.1 What is the effectiveness of physical devices (including support

garments, pessaries and dilators) for improving symptoms of pelvic floor

dysfunction?

10 Psychological therapy

10.1 What is the effectiveness of psychological interventions for women

with symptoms associated with pelvic floor dysfunction?

11 Behavioural approaches

11.1 What is the effectiveness of behavioural approaches (for example

toilet training, seating, splinting) for improving symptoms of pelvic floor

dysfunction?

12 Pharmacological management

12.1 What is the effectiveness of pharmacological management for

urinary incontinence associated with pelvic floor dysfunction?


emptying disorders of the bladder associated with pelvic floor

dysfunction?


faecal incontinence associated with pelvic floor dysfunction?


emptying disorders of the bowel associated with pelvic floor dysfunction?


sexual dysfunction associated with pelvic floor dysfunction?


chronic pelvic pain syndrome, including pelvic muscle pain, associated

with pelvic floor dysfunction?

13 Multidisciplinary pathways for non-surgical management of

symptoms associated with pelvic floor dysfunction

13.1 What competencies should be represented in a community-based

multidisciplinary team for the management of symptoms associated with

pelvic floor dysfunction?

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3.6 Main outcomes

The main outcomes that may be considered when searching for and

assessing the evidence are:

• prevention of pelvic floor dysfunction

• progression of symptoms or signs

• cure and improvement rates

• treatment-related adverse effects

• adherence

• health-related quality of life

• pain and discomfort

• need for further treatment (including surgical)

• mental wellbeing.

4 NICE quality standards and NICE Pathways

4.1 NICE quality standards

NICE quality standards that may need to be revised or updated when

this guideline is published

• Urinary incontinency in women (2015) NICE quality standard 77

NICE quality standards that will use this guideline as an evidence source

when they are being developed

• Pelvic floor dysfunction. Publication date to be confirmed

4.2 NICE Pathways

NICE Pathways bring together everything we have said on a topic in an

interactive flowchart. When this guideline is published, the recommendations

will be included in the NICE Pathway on pelvic floor dysfunction (in

development).

Other relevant guidance will also be added, including:

http://pathways.nice.org.uk/

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• Urinary incontinence and pelvic organ prolapse in women: management


• Mirabegron for treating symptoms of overactive bladder (2013) NICE

technology appraisal guidance 290

An outline based on this scope is included below. It will be adapted and more

detail added as the recommendations are written during guideline

development.

5 Further information

The guideline is expected to be published in August 2021.

https://www.nice.org.uk/Guidance/NG123

https://www.nice.org.uk/guidance/ta290

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You can follow progress of the guideline.

Our website has information about how NICE guidelines are developed.

© NICE 2019. All rights reserved. Subject to Notice of rights.


http://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines

https://www.nice.org.uk/terms-and-conditions#notice-of-rights

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6 Mapping recommendations from related

guideline

Guidelines Recommendations related to pelvic

floor dysfunction

Antenatal care for uncomplicated

pregnancies (2019) NICE guideline

CG62

1.1.1.1 Antenatal information should

be given to pregnant women

according to the following schedule.

•At booking (ideally by 10 weeks):

◦how the baby develops during

pregnancy

◦nutrition and diet, including vitamin

D supplementation for women at risk

of vitamin D deficiency, and details

of the Healthy Start programme

◦exercise, including pelvic floor

exercises

◦place of birth (refer to NICE's

guideline on intrapartum care)

◦pregnancy care pathway

◦breastfeeding, including workshops

◦participant-led antenatal classes

◦further discussion of all antenatal

screening

◦discussion of mental health issues

(refer to NICE's guideline on



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antenatal and postnatal mental

health)

Intrapartum care for healthy women

and babies (2017) NICE guideline

CG190

1.16.22 Observe the following basic

principles when performing perineal

repairs:

•Give the woman information about

the extent of the trauma, pain relief,

diet, hygiene and the importance of

pelvic-floor exercises. [2007]

Postnatal care up to 8 weeks after

birth. (2015) NICE guideline CG37

1.2.56 Women with involuntary

leakage of a small volume of urine

should be taught pelvic floor

exercises. [2006]

Urinary incontinence (update) and

pelvic organ prolapse in women:

management (2019) NICE guideline

NG123

1.1.2 Local MDTs for women with

primary stress urinary incontinence,

overactive bladder or primary

prolapse should include:

•2 consultants with expertise in

managing urinary incontinence in

women and/or pelvic organ prolapse

•a urogynaecology, urology or

continence specialist nurse

•a pelvic floor specialist

physiotherapist

and may also include:

•a member of the care of the elderly

team








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•an occupational therapist

•a colorectal surgeon. [2019]

1.1.4 Regional MDTs that deal with

complex pelvic floor dysfunction and

mesh-related problems should

review the proposed treatment for

women if:

•they are having repeat continence

surgery

•they are having repeat, same-site

prolapse surgery

•their preferred treatment option is

not available in the referring hospital

•they have coexisting bowel

problems that may need additional

colorectal intervention

•vaginal mesh for prolapse is a

treatment option for them

•they have mesh complications or

unexplained symptoms after mesh

surgery for urinary incontinence or

prolapse

•they are considering surgery and

may wish to have children in the

future. [2019]



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mesh-related problems should

include:

•a subspecialist in urogynaecology

•a urologist with expertise in female

urology

•a urogynaecology, urology or

continence specialist nurse

•a pelvic floor specialist

physiotherapist

•a radiologist with expertise in pelvic

floor imaging

•a colorectal surgeon with expertise

in pelvic floor problems

•a pain specialist with expertise in

managing pelvic pain

and may also include:

•a healthcare professional trained in

bowel biofeedback and trans-anal

irrigation

•a clinical psychologist

•a member of the care of the elderly

team

•an occupational therapist

•a surgeon skilled at operating in the

obturator region

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•a plastic surgeon. [2019]



mesh-related problems should have

ready access to the following

services:

•psychology

•psychosexual counselling

•chronic pain management

•bowel symptom management

•neurology. [2019]

1.3.4 Undertake routine digital

assessment to confirm pelvic floor

muscle contraction before the use of

supervised pelvic floor muscle

training for the treatment of urinary

incontinence. [2006, amended

2013]

1.4.4 Offer a trial of supervised

pelvic floor muscle training of at least

3 months' duration as first-line

treatment to women with stress or

mixed urinary incontinence. [2019]

1.4.5 Pelvic floor muscle training

programmes should comprise at

least 8 contractions performed 3

times per day. [2006]

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1.4.6 Do not use perineometry or

pelvic floor electromyography as

biofeedback as a routine part of

pelvic floor muscle training. [2006]

1.4.7 Continue an exercise

programme if pelvic floor muscle

training is beneficial. [2006]

1.4.9 Do not routinely use electrical

stimulation in combination with pelvic

floor muscle training. [2006]

1.4.10 Electrical stimulation and/or

biofeedback should be considered

for women who cannot actively

contract pelvic floor muscles to aid

motivation and adherence to

therapy. [2006]

1.5.18 For women whose primary

surgical procedure for stress urinary

incontinence has failed (including

women whose symptoms have

returned):

•seek advice on assessment and

management from a regional MDT

that deals with complex pelvic floor

dysfunction or

•offer the woman advice about

managing urinary symptoms if she

does not wish to have another

surgical procedure, and explain that

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she can ask for a referral if she

changes her mind. [2019]

1.6.3 For women who are referred

for specialist evaluation of vaginal

prolapse, perform an examination to:

•assess and record the presence

and degree of prolapse of the

anterior, central and posterior

vaginal compartments of the pelvic

floor, using the POP‑Q (Pelvic

Organ Prolapse Quantification)

system

•assess the activity of the pelvic floor

muscles

•assess for vaginal atrophy

•rule out a pelvic mass or other

pathology. [2019]

1.6.4 For women with pelvic organ

prolapse, consider using a validated

pelvic floor symptom questionnaire

to aid assessment and decision

making. [2019]

1.7.5 Consider a programme of

supervised pelvic floor muscle

training for at least 16 weeks as a

first option for women with

symptomatic POP‑Q (Pelvic Organ

Prolapse Quantification) stage 1 or

stage 2 pelvic organ prolapse. If the

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programme is beneficial, advise

women to continue pelvic floor

muscle training afterwards. [2019]

1.7.6 Consider a vaginal pessary for

women with symptomatic pelvic

organ prolapse, alone or in

conjunction with supervised pelvic

floor muscle training. [2019]

1.11.17 For women with bowel

complications that are directly

related to mesh placement, such as

erosion, stricture or fistula, discuss

treatment with a regional MDT that

has expertise in complex pelvic floor

dysfunction and mesh-related

problems. Use this discussion to

formulate an individualised treatment

plan with the woman. [2019]

Faecal incontinence in adults:


CG49

1.4.1 People who continue to have

episodes of faecal incontinence after

initial management should be

considered for specialised

management. This may involve

referral to a specialist continence

service, which may include:

•pelvic floor muscle training



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•bowel retraining

•specialist dietary assessment and

management

•biofeedback

•electrical stimulation

•rectal irrigation.

Some of these treatments might not

be appropriate for people who are

unable to understand and/or comply

with instructions. For example, pelvic

floor re-education programmes might

not be appropriate for those with

neurological or spinal disease/injury

resulting in faecal incontinence.

1.4.2 Healthcare professionals

should consider in particular whether

people with neurological or spinal

disease/injury resulting in faecal

incontinence, who have some

residual motor function and are still

symptomatic after baseline

assessment and initial management,

could benefit from specialised

management (see also section 1.7).

1.4.3 Any programme of pelvic floor

muscle training should be agreed

with the person. A patient-specific

exercise regimen should be provided

based on the findings of digital

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assessment. The progress of people

having pelvic floor muscle training

should be monitored by digital

reassessment carried out by an

appropriately trained healthcare

professional who is supervising the

treatment. There should be a review

of the person's symptoms on

completion of the programme and

other treatment options considered if

appropriate.

Urinary incontinence in neurological

disease: assessment and


CG148

1.1.3 Undertake a general physical

examination that includes:

•measuring blood pressure

•an abdominal examination

•an external genitalia examination

•a vaginal or rectal examination if

clinically indicated (for example, to

look for evidence of pelvic floor

prolapse, faecal loading or

alterations in anal tone).

1.4.1 Consider pelvic floor muscle

training for people with:

•lower urinary tract dysfunction due

to multiple sclerosis or stroke or

•other neurological conditions where

the potential to voluntarily contract

the pelvic floor is preserved.




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Select patients for this training after

specialist pelvic floor assessment

and consider combining treatment

with biofeedback and/or electrical

stimulation of the pelvic floor.

Weight management before, during

and after pregnancy (2010) NICE

guideline PH27

Recommendation 3

•During the 6–8-week postnatal

check, or during the follow-up

appointment within the next 6

months… Advice on healthy eating

and physical activity should be

tailored to her circumstances. For

example, it should take into account

the demands of caring for a baby

and any other children, how tired she

is and any health problems she may

have (such as pelvic floor muscle

weakness or backache).

◦If pregnancy and delivery are

uncomplicated, a mild exercise

programme consisting of walking,

pelvic floor exercises and stretching

may begin immediately. But women

should not resume high-impact

activity too soon after giving birth.



Documents

Guideline scope Pelvic floor dysfunction: prevention and